ECHOCARDIOGRAPHY What the intensivist should know OVERVIEW - PowerPoint PPT Presentation

ECHOCARDIOGRAPHY What the intensivist should know…

OVERVIEW • Background • Why ECHO? • Limitations • How to learn ECHO • What you need to know • Where we are heading

BACKGROUND

BACKGROUND

COLLEGE AKNOWLEDGEMENT

WHY DO WE NEED TO LEARN ECHO? • Filling the void • Differentiating shock • Tamponade post cardiac surgery • Management of cardiovascular supports • ECHO in cardiac arrest

LIMITATIONS • Scope of practice • Impact of • False positives • False negatives • Formal studies • Advanced studies

HOW TO LEARN ECHO • BOOKS • COURSES • WEBSITES • HANDS ON SACNNING • SUPERVISION • POST GRAD CERT/DIPLOMA

WEBSITES

CICM GUIDELINE • Attend an approved ECHO course • Find a supervisor • Perform 35 focussed cardiac ultrasound cases • Record images/ Write in notes • Complete and pass an online MCQ exam @CICM • In the furture- there may be a ‘live’ exam

CICM GUIDELINE • Basic physics • Machine setup • Patient details • Image optimization • Basic views (PLA/ PSA/ A4C/ Scand IVC) • Focussed questions looking for pathology • Limitations • Colour/Doppler not included

CICM GUIDELINE- FOCUSSED QUESTIONS • 1. Is the LV significantly impaired? • 2. Is the LV dilated? • 3. Is the RV function grossly abnormal? • 4. Is the RV dilated? • 5. Is there any pericardial fluid/tamponade? • 6. Is the patient significantly hypovolaemic? • 7. Conclusion addressing relevant clinical question

SHOCK ALGORITHM • Assess volume status exclude hypovolaemia • IVC • LV EDV • Assess contractility of LV exclude LV failure • Exclude tamponade • Assess right heart function exclude PE • Exclude pneumothorax • Exclude AAA ……..takes about 3 minutes….

CARDIAC WINDOWS • Parasternal • Long axis • Short Axis • Apical • 4 chamber • 2 chamber • Subcostal

PROBE POSITION • Parasternal Long Axis

PARASTERNAL LONG AXIS

PARASTERNAL LONG AXIS

PARSTERNAL SHORT AXIS

PARASTERNAL SHORT AXIS

PSAX

PARASTERNAL SHORT AXIS

APICAL 4 CHAMBER

APICAL 4 CHAMBER

APICAL 4 CHAMBER

APICAL 2 CHAMBER

APICAL 2 CHAMBER

SUBCOSTAL

SUBCOSTAL VIEW

SUBCOSTAL

LV CONTRACTILITY • Overview • Visual ‘Gestalt’ • Fractional area change (FAC) (40-60%) • Simpsons method • Mild impairment EF 50-70% • Moderate impairment EF 30-50% • Severe impairment EF <30%

LV CONTRACTILITY- NORMAL

LV CONTRACTILITY- NORMAL

LV CONTRACTILITY- NORMAL

LV CONTRACTILITY- NORMAL

LV CONTRACTILITY- NORMAL

SIMPSONS

SIMPSONS

THE RIGHT VENTRICLE • Shape • Size • Function • Assesment

VOLUME AND PRESSURE OVERLOAD

RV/LV RATIO- NORMAL (0.6:1)

CLASSIC SIGNS OF PE • Dilated RV • Septal flattening • Impaired RV • Tricuspid regurgitation • McConnels sign • Raised PA pressures (RVSP) • Visible clot

SEPTAL FLATTENING

SEPTAL FLATTENING

SEPTAL FLATTENING

VOLUME STATUS- IVC IVC • • Abdominal probe • Sub-costal view- longitudinal • Using liver as a window • Measure IVC 2cm distal to diaphragm • Collapsibility with respiration • Visual gestalt • M-mode

IVC DIAMETER AND CVP

IVC

IVC

IVC ANALYSIS • Absolute diameter • <1cm Correlates with a CVP ~ <5cm H20 • 1-2cm Correlates with a CVP ~ 5-15cm H20 • >2cm correlates with a CVP ~ >15cm H20 • Variability • Ventilated patient • >12% collapsibility indicates volume responsiveness • Unventilated patient • >50% collapsibility indicates volume responsiveness

VOLUME STATUS-IVC